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CGH Assessment: Within the Context of Cervical Spine Examination

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CGH Assessment: Within the Context of Cervical Spine Examination. Cervical Treatment Based Classification. Fritz & Brennan (2007). Physical Examination Objectives. Identify c ervical contribution to HA’s Is there a comparable sign

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Presentation Transcript
physical examination objectives
Physical Examination Objectives
  • Identify cervical contribution to HA’s
  • Is there a comparable sign
  • Identify Impairments that may be directly or indirectly contributing to HA’s
  • Develop Prognosis
    • SINSS, Contributing factors, Psychosocial Issues
history important questions
History – Important Questions
  • Age of onset and duration
  • MOI- history of trauma including MVA, manipulations, falls, quick mvts, pregnancy.
  • Nature and quality of HA’s (unilateral, bilateral, throbbing, pulsating, constant, intermittent, duration)
  • Associated Symptoms – nausea, photo or phonobia, “5 D’s”
  • Aggravating and alleviating factors
    • Posture, Stress, Response to medication.
  • How are symptoms changing
  • Previous Treatments
assessment mechanics of upper cervical spine
Assessment & Mechanics of Upper Cervical Spine
  • C0-C1
    • Flexion/Extension
      • 35 degrees ;10 flexion/25 extension (Sizer 2005)
      • Axis through External Auditory Meati
      • Occipital condyles roll in same direction, glide opposite (1,2)
      • Unilateral limitations in flexion result in deviation to opposite side (3)
        • Limitation in R OA flexion, chin will deviate to left with OA flexion.
      • Unilateral limitations in extension result in deviation to same
        • Limitation in R OA extension, head will tilt to the right

Greater amounts of Upper cervical flexion achieved in Cervical retraction, extension with protraction.

assessment mechanics of upper cervical spine1
Assessment & Mechanics of Upper Cervical Spine
  • C0-C1
    • Side-Bending
      • Axis through the nose
      • Occipital condyles roll to same side and slide opposite
      • Obligatory motion of the Atlas* (Paris & Sizer)
        • Translate to same side and rotate opposite ( SBR, atlas will translate right and rotate left).
      • Obligatory motion at C2-3*
        • Rotation to same side as SB (due to Alar ligament)
        • OA will not SB if C2 cannot rotate on C3 to same side. (1)
        • C2-3 “Keystone to Upper Cervical motion” (1)
assessment mechanics of upper cervical spine2
Assessment & Mechanics of Upper Cervical Spine
  • C1-C2
    • 40-45 degrees rotation to each side
    • With right rotation the right C1 facets slides posterior to C2 facet and the left C1 facet slides anterior to left C2 facet
    • The occiput will SB opposite direction of rotation (1)
      • Absence of this will produce an obvious ipsilateral SB with rotation
assessment lab sitting
  • Observe Posture
  • AROM
    • Cervical physiologic
    • AA Rotation
    • OA SB
  • Cranial Nerves
  • Palpation of Sub-Occipital Triangle
  • Upper Cervical LigamentousTesting
    • Transverse
    • Alar
forward head posture
Forward Head Posture
  • Subcranial Posterior Rotation & Anterior head Translation leads to a decrease in Craniovertebral Angle
    • O/A and AA Functional spaces Altered
      • Compression of subcranial structures including the vertebral arteries and their sympathetic nerves, the first two cervical nerves, and soft tissue. (1)
    • Hypomobility about the upper cervical spine and upper thoracic spine (1,2)
    • Mid-Cervical hypermobility (3)
    • Alterations in muscle length tension relationships and muscle function (Upper Cross Syndrome) (3)

Observation / Postural Examination

  • View patient’s posture from the side
  • Assess:
  • Forward head posture
  • Shoulder carriage
  • Typical patterns include:
    • Sub-Cranial Posterior Rot.
    • Flexed (rounded) T1-T2
    • Extended (flat) T3-T7
    • Flexed (rounded) T8-T12
forward head posture upper cross syndrome 3
Forward Head Posture – Upper Cross Syndrome (3)
  • Weakened Muscles Shortened Muscles
    • Deep Cervical Flexors Sub-Occipitals
    • Lower and Mid Trapezius Upper Trapezius
    • Serratus Anterior Pectorals
craniovertebral angle fern ndez de las pe as c et al 2007
Craniovertebral Angle – Fernández-de-las-Peñas C et al (2007)
  • Measured Craniovertebral Angle by measuring the angle formed by horizontal line through C7 and a line form C7 to the Tragus of the Ear.
  • Smaller angle associated with CTTH (4,5)
forward head posture assessment
Forward Head Posture - Assessment
  • Visual Observation
    • Sitting
      • Manubrium to MentonianSymphysis (lowest point on mandible) to Malar Bone
      • Position of SCM (60 deg angle) (structure changes function)
      • Palpate C0-C2 space
      • CV Angle
      • Ability to correct
    • Standing
      • Head to Wall (measure).
  • Brame M. Headaches and the Upper Cervical Spine. Course Handout. North American Seminars 2005
  • CranioMandibularSytem. On-Line Course Material. University of St. Augustine for Health sciences 2010.
  • Lau et al. Clinical measurement of craniovertebral angle by electronic head posture instrument: A test of reliability and validity.Manual Therapy 2009; 14:363–368
  • Moore M. Upper Crossed Syndrome and its Relationship to Cervicogenic Headache. Journal of Manipulative and Physiological Therapeutics 2004;27:414-20
  • Fernandez-de-las-Penas C. Performance of the Craniocervical Flexion Test, Forward Head Posture, and Headache Clinical Parameters in Patients With Chronic Tension-Type Headache: A Pilot Study. JOSPT 2007;37(2):33-39
upper cervical ligamentous testing1
Upper Cervical Ligamentous Testing
  • Transverse Ligament (1)
    • Prevents separation of C1 and C2
    • Prevents tipping of the Dens into brainstem and spinal cord
  • Alar Ligament
    • Assists Transverse Ligament
    • Taught in extension, SB and ipsilateral rotation
    • Responsible for coupled motions
upper cervical ligamentous testing sharp purser
Upper Cervical Ligamentous Testing – Sharp Purser

Purpose: Position of Atlas and Dens (Transverse Ligament)

Patient: Sitting

Technique: The palm of one hand is placed on the patient’s forehead while the spinous process of the axis is held by a pinch grip of th opposite hand. Then the head and neck are the gently

flexed. Through palmar pressure on the forehead, the occiput and atlas are translated posteriorly.

Positive: Decrease symptoms or clunk.

Mintken Pet al . JOSPT 2008;38(8):465-475

upper cervical ligamentous testing alar ligament
Upper Cervical Ligamentous Testing – Alar Ligament
  • Patient seated in upright posture
  • Stand at patients side and achieve pincher grip of SP of C2 (you many need to flex cervical spine if patient has significant FH)
  • Side-bend head to one side
  • Test: You should feel an obilgatory movement of the SP of C2 moving away from the side the side –bending is occurring. This is due to obligatory rotation to same side with intact Alar Ligament.
palpation of sub occipital triangle
Palpation of Sub-Occipital Triangle
  • Base of Occiput to TP of Atlas
  • TP of Atlas to SP of C2
  • C2 to Base of Occiput
  • Note texture of tissue

and provocation.

assessment lab supine
  • PROM
    • OA flexion , extension and SB
    • AA Rotation
      • with flexion and/or SB
    • C2-3 Accessory Glides
    • General Upper Thoracic (PA)
    • Palpation (length)
      • Trapezius
      • SCM
      • Sub-occipitals
      • Splenius
  • Muscle Performance (Motor Control)
    • DCF with or without biofeedback
oa extension and flexion
OA Extension and Flexion

Patient supine with cervical spine in neutral. Cradle head with both hands with thumbs resting on temporal region. Gently nod occiput forward and backward around a transverse axis through the External Auditory Meati. Bias flexion to the right or left by rotating head 20-30 degrees in same direction. Alternate technique is to place one hand on forehead and use a coupling motion with both hands to induce flexion/extension

Cradle patients head with both hands. Use the radial border of your second phalanx to lift the occiputanteriorly. Bias extension towards the right by lifting up on the left, assessing the left side.

upper cervical ligamentous testing anterior shear test
Upper Cervical Ligamentous Testing – Anterior Shear Test

Purpose: Transverse Ligament

Patient: Supine

Position: Head is supported with second index fingers resting between occiput and C2

Technique: Head and C1 are lifted anteriorly

Positive: Produces nystagmus, paresthesias of lips, hands toes, increase patients symptoms. Note end feel

Mintken Pet al . JOSPT 2008;38(8):465-475.

oa sidebending
OA - Sidebending
  • Patient supine with head in neutral.
  • Grasp head with both hands with hand/thumb on side where SB to occur on mandible.
  • Use coupled motion to induce SB through subcranial region.
  • Can use abdomen to perform comfortable axial load to stabilize cervical spine.
  • 10-15 degrees is normal
aa rotation with flexion
AA Rotation with Flexion
  • Cervical Spine is fully flexed with patients head supported by clinicians abdomen.
  • Cervical Spine is rotated fully to the both sides.
  • Note range of motion, end-feel and patient response.
aa rotation with sb
AA Rotation with SB
  • Cervical spine is resting on pillow in neutral flexion/extension.
  • SB to one side to first barrier. Rotate head gently to opposite side
  • Important: No more than 40-45 degrees should be available. Assess range, quality and pain. Do not lose SB
palpation and uglide of c2 3 r
Palpation and Uglide of C2-3 (R)
  • Patient supine with heads resting on pillow
  • Palpate the articular pillar of C2 with your finger tips and slide right index finger down along pillar to approximate the middle phalanx.
  • Rotate head and neck minimally to the right without feeling motion takngpalce at C2-3. Add slight SB to left using mostly your trunk
  • Use your contact point to provide a “lifting” motion in a 45 degree plane toward patients left eye
motor performance of the dcf
Motor Performance of the DCF

O’Leary S et al 2009

With Biofeedback:

Cervical Spine is in neutral. Inflate cuff to 20 mm hg. Instruct patient to perform nodding movement (yes) to 22 mm hg for 10 secs. Provide 10 sec rest and move up to 30 in increments of 2 if patient able to perform. Should achieve 26-30 mm hg.

Without Biofeedback:

Retract neck and perform chin tuck. Lift head one inch. Maintain tucked chin and hold head up.

Neck pain: 24 Without: 38

Childs JD et al 2008

assessment lab prone
Assessment Lab - Prone
  • Unilateral PA’s
    • C0-1
    • C2-3
    • C1-2
    • T2-4 Apophyseal and CT joints

Tip: In these techniques utilize shoulder adductors and trunk to grade force while relaxing the thumbs.

c2 3 unilateral pa
C2-3 Unilateral PA

Head and neck are in neutral. Take up slack in soft tissue. PA is applied to the articular pillar of C2 assessing further rotation of C1 on C2. Using arms (pectorals) and trunk to impart pressure which is mild. Note resistance and reproduction of pain.

Without rotation assess C2-3. Can be a treatment technique with graded oscillations

c1 c2 unilateral pa
C1-C2/ Unilateral PA

Head is rotated 30 degrees to the side tested. Take up slack in soft tissue. PA is applied to the articular pillar of C2 assessing further rotation of C1 on C2. Using arms (pectorals) and trunk to impart pressure which is mild. Note resistance and reproduction of pain.

Can be a treatment technique with graded oscillations.

With Permission –

  • Sizer PS et al. Diagnosis and Management of Cervicogenic Headache. Tuitorial. Pain Practice 2005; 5(3): 255-274
  • Paris SV. S3 Seminar manual. University of St. Augustine. Patris, Inc 4th Edition 2000.
  • Cervico-Thoracic Integration. Course Manual. Institute of Physical Art 2002.